The media has been reporting key missing documents at San Onofre Nuclear Reactor (SONR) related to safety and failing equipment (*)

I am deeply troubled and extremely concerned by this “lack of documentation”, as we should all be, especially for a critical life-threatening process involving critical failing equipment which is endangering plant reactor personnel, surrounding communities and the environment.

But it is now also extremely suspect that key documentation is missing, which casts suspicion on plant personnel and the company.

This is even more suspect because design review and approval changes are always done by a team of different departments and by different levels of plant personnel.

So several people at several departments should or could have a copy of the missing documentation.

My Audit Experience of Chemical Manufacturing Plants:

I audited chemical manufacturing plants and chemical engineering divisions for a large multi-billion multinational. I traveled for about 3 years (traveling 95% of the time worldwide – primarily in the south of the US – Louisiana, Alabama, and Texas; and Chile, and Brazil, etc). I traveled to 28 countries and 22 states.

A team of 4 or 5 of us would spend about 3 months doing a top-to-bottom audit of the chemical plant in question and then move on to the next plant.

I audited these plants to prevent a mechanical or process failure that could cause an explosion of the plant, or a release into the communities. I would lead our team in weekly discussions with key plant personnel as to our scope of work, our status, findings, recommendations and key issues. I audited according to:

Also with permission from our internal audit senior management, I would coordinate our reviews with plant personnel and also developed a relationship with the particular state’s equivalent of the EPA to determine and ensure the manufacturing plant was complying with our company’s and state’s environmental protection requirements. This was a win-win for our company and the state’s citizens.

There were other times that our internal audit team had to push back, because some corporate management and some plant personnel wanted to push back on our compliance requirements because they argued we needed to make and take a “Business Cost-Effectiveness” attitude.

I said that if we already knew what the Best Available Technology, and the best available process was that we needed to follow, why would we abandon this, and run and increase the company’s reputational risk and which could cost us more in the long run in lost lives, loss of a plant, or greater costs from after-the-fact remediation efforts and/or plant shutdown. I would ask, do you want to have headlines read “XYZ pollutes and kills people.”?

I would also half-jokingly reply, please tell us in writing that you want us to abandon our experience and our judgment and to use the FORD-Pinto Cost-Benefit (Negligence – Efficiency) analysis. Ford Pinto chose not to add about $11 to the manufacturing cost of a Ford Pinto even though they knew this would save lives from preventing gas tank explosions in an accident.

1) MANAGEMENT OF CHANGE Procedures (MOC) [ 1910.119(l)(1) ]
This guides the review and approval of DESIGN changes and is very rigorously documented.

2) MECHANICAL INTEGRITY [ 1910.119(j) ]
Key/critical components in the whole manufacturing process are identified so that they withstand operations, do not fail, and do not cause a plan explosion or leak of dangerous gases or elements that can kill plant personnel, or others in surrounding communities.

Equipment under Mechanical Integrity category must be well maintained and any changes especially moving to use a NEW part (other than routine replacement with a previously approved part “for a replacement in kind”) requires review and approval under MOC procedures.

3) PROCESS HAZARD REVIEWS/PROCESS HAZARD ANALYSIS [1910.119(e)(1) ]
Evaluates the impact especially of the proposed Mechanical Integrity NEW PART being considered to be used.

For all of these steps, there are various levels of approvals in different departments.

4) RECORD RETENTION POLICIES AND PROCEDURES
This usually guides the retention and destruction of documents, and what typically happens is that companies/personnel may RETAIN documents LONGER than they are required (since they may forget to follow destruction procedures);

It is extremely rare that someone goes out and DESTROY key/critical documentation EARLIER than Required, especially MOC or Mechanical Integrity documentation, or one that is supposed to demonstrate why they have not increased safety risk with this design change.

5) DEVIATIONS [ 1910.119(d)(2)(i)(E) ]

An Evaluation of Consequences of deviations including those affecting the safety and health of employees.

6) PROCESS SAFETY INFORMATION [1910.119(d)]

SAFETY, SAFETY, SAFETY and DOCUMENTATION guides everything in a very regulated process.

About Francisco Barragan

6 Comments

*They put high velocity tubes into the facility to replace the failing old technology. Then they cranked up the power to try to make an addtional 50% more power and that that concept failed miserably. The cost was $631 million dollars by the way…five years ago. Now they will have to replace the worn out new tubes back to the old tubes for about $400 million dollars…..just to get back to what they had before. This means that the consumer of course will eventually pay the freignt for their failed repair job.

*Public Utilities…..ever heard of them. Controlled by the Public Utilities Commission of the State of California. Every time there is a rate hike….it needs to be approved by the PUC. So, start your letter writing campaign today by going to their web site and making your comments and feelings known NOW…..before Edison and SD PG & E and the rest all ask to hike rates cause………well, you know………don’t you….really?

Remember the bad old days when Enron ripped off the entire state for billions and billions…? Same stuff….different day!

I knew these so called “missing” records existed somewhere, as I described above.

I think they were being withheld because as the independent reviewer (Mr. Arnie Gunderse) makes clear at the link above:

1) There were 40 SEPARATE triggers requiring REGULATORY review and approval of these safety design changes.

2) The Regulatory review and approval was NOT Obtained.

3) And significant and critical information was withheld from these regulators.

4) And these noncompliance violations are more significant because the critical equipment failed, and these failures could have been prevented if the design changes had been independently challenged.

TWO ISSUES:
A) REQUIRE INDEPENDENT COMPLIANCE.
As a professional auditor, especially in the area of regulatory safety compliance, I always look for the opportunity to be a trusted business partner and if done professionally an SRO (Self Regulatory Org approach); however, it seems that because SCE/San Onofre failed to follow critical safety requirements and because this could have resulted in loss of lives, loss of the reactor, and harm to the surrounding population and the environment, I think SCE/San Onofre IS A PRIME CANDIDATE for a multi-year (i.e. 3-5 years) CIA (CORPORATE INTEGRITY AGREEMENT) – which requires them to be closely supervised with independent annual EH& S (Environmental, Health and Safety) audits and reviews to ensure they do NOT violate the regulatory requirements again.

B) DECISION TO DISREGARD REGULATIONS:
WHO in management and HOW HIGH was the decision made and WHEN was it made to DISREGARD the safety regulations and to NOT conduct the independent design changes review and approval.

HOW INTENTIONAL or UNINTENTIONAL WAS THIS?
Can the individuals in the company’s process be trusted to comply? If so, how is this monitored, and controlled to prevent recurrence of this violation and protect the surrounding population.